>> Good evening.

I'm psychiatrist Jay Fawver live from Fort Wayne , Indiana.

Welcome to Matters of the Mind now in its third year, Matters of the Mind is a live call in program where you have the chance to choose the topic for discussion.

>> So if you have any questions concerning mental health issues, you may contact me by calling me in the Fort Wayne area at (969) 27 two zero or if you're calling long distance you may call toll free at 866- (969) to seven to zero.

Now on a fairly regular basis where broadcasting live every Monday night from our spectacular PBS Fort Wayne studios which lie in the shadows of the Fort Wayne campus and if you'd like to contact me with an email question that I can answer on the air, you may write me a via the Internet at matters of the mind all one word at a dog that's matters of the mind at WFA and I'll start tonight's program with a question I recently received.

>> It reads Dear Not Your Father.

I hear that Lexapro is often used as the first antidote.

Why does it work for some people and not others?

Well, it'll work in about one out of three people statistically where they'll feel well they might have a oh about a two out of five chance perhaps of not feeling so well over the course of a year.

But initially they'll feel well with Lexapro Lexapro like any medication needs to be used for the right individual, for the right conditions.

So No one you have to make sure it's the right condition if you have what's called bipolar disorder where you having big highs and big lows, Lexapro might not work for you so well because any antidepressant can make the highs higher and more frequently occurring.

So Lexapro needs to be given specifically to somebody who has depression or anxiety number one.

>> Secondly, Lexapro specifically and selectively will increase is chemical called serotonin.

Serotonin was the neurotransmitter that was most extensively studied back in the 1980s and 1990s.

>> Prozac came out in nineteen eighty seven and when Prozac came out Lexapro followed that several years later.

>> But these medications specifically and selectively increased serotonin in doing so they typically do not cause weight gain.

They don't cause you to be lightheaded.

They don't cause a lot of side effects that the older antidepressants cause back in the 60s and 70s so the nice thing about the medications like Lexapro that increase serotonin is that they don't cause a lot of side effects that the older medications caused.

However, Lexapro is very selective in what it does and for some people it just won't be the right medication.

There's a particular gene called an SLAC six for serotonin transporter gene and that serotonin transporter gene can be somewhat predictive in telling who's going to do well with Lexapro and who might not.

>> And if you have two of the short illegals on it, a gene is called an illegal and if you have two the short illegals instead of the two long illegals are less likely to respond to Lexapro.

So to short Leal's make you less likely to respond to medications that are specific to their mechanisms of action based on the serotonin transporter mechanism.

So that could be a reason why you might not respond to Lexapro just based on your genetics.

Another thing that will consider will be a family history of medication response.

If you've had a mother, father, brother or sister who just didn't do very well with Lexapro, we might not want to give you Lexapro either.

So we will consider the family history of medication response.

Another aspect of genetics will be if you typically are a fast metabolism on this particular gene called C to 2C nineteen to C nineteen breaks down Lexapro and if you are a fast metabolize on that basically you're chewing complex Parool fast so it might not work for you because you're getting to lower blood levels and in that case you'd have to go to really higher blood levels but that had to be done in a very close monitoring.

>> Another factor that comes to mind why why somebody might not respond to Lexapro would be if somebody had a lot of childhood trauma.

If you've had a lot of childhood trauma, you're less likely to respond to the medications that specifically and selectively enhance serotonin like Lexapro as well as Celexa Zoloft, Prozac, Paxil.

These are all medications that are commonly used.

But if you endured a lot of childhood trauma they might not work as well.

I don't know why but you put the childhood trauma together with the genotype for the SLC six eighty four of the short baliles and you put all that together and you just might not responsible to Lexapro.

The way we measure childhood trauma will often be by this particular scale.

It's called Adverse Childhood Experience Scale called an ace ACEEE There's ten questions and these ten questions were developed years ago by a large health maintenance organization looking at people people's risk factors for obesity and why some people gain more weight than others.

Any risk factor for obesity?

The identified would be childhood trauma.

So they put together all the different types of childhood traumas that could occur and there's hundreds of them.

But they found ten childhood traumas that were most likely to predict childhood predict obesity later on in life as well as to predict diabetes, cancer, lung disease all these are medical conditions and now we have found the same ACE questionnaire the adverse childhood experience questionnaire.

If you score four or more it's highly predictive you're going to have more mental health problems.

So it's a it's a questionnaire that I frequently use for new patients in my office because I want to know if you've had childhood experiences that were very traumatic.

If you were it's less likely you're going to respond to certain medications and among those medications can be the so-called SSRI which include Lexapro.

Thanks for your question.

Let's go to our first caller.

Hello Ron.

Welcome to Matters of Mind.

>> Ron, you want to know why is Bruce Byron prescribed for anxiety abuse?

Ron Ron is a very specific and selective medication for one of the 14 different serotonin receptors serotonin gets shot out of a neuron that's a serotonin neuron that comes from the Ralph Nucleus which is way down here in the middle part of the brain.

>> So you spray out the serotonin from these little serotonin shotgunned so to speak and the shotgun spray out serotonin and they go to fourteen different targets which are called receptors.

>> One of those receptors a serotonin one a receptors and what the abuse Spirent does wrong if you have two little serotonin getting shot out you'll get a stimulation of serotonin by beuse biron but if you have too much serotonin being shot out into the periphery in your brain, the abuse birhan will actually block serotonin.

>> It's called a partial agonist for serotonin one a receptor is so specific for this one a receptor receptors go by letters and numbers and one is one of them and if you find a tune like a thermostat that particular receptor you'll theoretically decrease the anxiety for somebody run where we keep you spiral and use the most will be for somebody who has ruminative worry.

>> They dwell on things they don't have obsessions where they're thinking about these outrageous thoughts that don't make any sense to them but they just can't get them off their mind.

>> They worry about doubts and what might happen in the future and they seem to be very reasonable for them.

So the difference between an obsession and a generalized rumination which is a worry, an obsession is where you're thinking about things that you know don't make sense but you can't get them off your mind and sometimes with obsessions you end up doing things like washing your hands repeatedly because you have this thought that you know it's not realistic but you have this thought that your hands are dirty, you've got germs on them and you just got to keep washing washing or washing with ruminative worry which we call generalized anxiety.

>> That's where you're having an overwhelming sense that bad things are going to happen.

>> You're always doubting and fearing things particularly about the future.

You're not thinking so much about the past with generalized anxiety that's more indicative of depression when people have depression they're always regretting things they did in the past.

They can't get their minds off their past transgressions.

They just get preoccupied with them.

They get focused on what happened in the past with generalized anxiety.

They're often looking forward but they're worried about what's going to happen in the future and they become overwhelmed with abuse.

Spiral is going to be more helpful for people having difficulty with worry and anxiety in the future and having doubts and over and feeling overwhelmed about what might happen in the future days.

Now you spiral and Ron will not typically be a good replacement for Xanax, Valium, Ativan, Klonopin.

>> We thought it would be back in 1986 when became available.

I was a resident in psychiatry at the time Xanax had been used for about three years by at times Xanax is known as alprazolam and it was very good for anxiety and panic.

So Xanax had been used for a few years.

>> But the problem was as you could imagine, Ron, a lot of people were getting hooked on Xanax and they couldn't stop using it.

They took higher and higher doses.

So Spirent came out as a whole different mechanism of action to try to help with anxiety.

>> So Xanax works here on the amygdala.

It's a little almond shaped part of the brain and the part of the brain called the temporal lobe and the amygdala is the volume control for anxiety, fear and anger.

And the idea with Xanax is you go to this part of the brain here, turn down the volume control there and if the volume control is turned out in the anxiety center of the brain, you can think more clearly because the anxiety center can overwhelm and hijack the thinking logical part of the brain.

That's why people who have panic and anxiety of fear and anger they can't think clearly is because the thinking part of the brain is in the front whereas the emotional controls down here in the temporal lobe that's the part of the brain that Xanax will work upon.

Here's the problem, Ron.

When you use Bew Spyro, it's working on the front part of the brain and it's trying to help you with the thinking part of the brain is help trying to help you with worry and rumination.

But the problem is the anxiety volume control is still turned up too high so abuse spiral might not help the best for panic and extreme anxiety and extreme anger because this amygdala down here is too hot and still working overtime.

>> So bu Spirent is better for somebody who's worrying about things.

Xanax is better for people who are having difficulty with overwhelming panic and anxiety ,fear and anger.

Now the thing about Xanax is if you're going to use it, use it very briefly.

>> A general rule of thumb is you don't want to use it for more than two weeks we will prescribe Xanax not uncommonly for people who need to get on an airplane.

>> They need Xanax just for a few doses to get them through a really rough spot.

But we don't want to prescribe it for more than a couple of weeks because the longer you take Xanax the more likely you're going to have trouble with concentration motivation.

It slows the processing speed of the brain and that's like a computer being slower.

You know, back in the old days we had the slower computers where you click on your mouse and you'd have to wait a couple of seconds which seemed like an eternity for the screen to change if you have a slow computer it's very frustrating.

By the same token, if you have a slow brain because you have slow processing speed it cause you to have trouble with concentration and you'll go to your doctor said I just can't function when somebody tells me they just can't function it typically means they have slow processing speed in their brain so they're not able to make decisions, they're not able to communicate, they're not able to talk to other people.

>> So the slow processing speed can be a big disadvantage in terms of getting through your day to day expectations and that's what Xanax will often cause.

So Xanax at a dosage of five milligrams three times a day can give you the same reaction time and the processing speed that you would have is if you were well legally drunk zero point zero eight milligrams per deciliter for alcohol so you can have a blood alcohol a point 08.

Well, that's kind of what it's like to have a Xanax on board eight point five milligrams, three times a day.

It gives you the same degree of reaction time and the same difficulty with concentration.

So for that reason and in twenty twenty one twenty twenty two as we've progressed and giving patients medications for anxiety, we try not to start with Xanax, we try not to start with medications that Clonazepam or Klonopin we did years ago it was I mean those are the main kind of medication we had.

Now we realize that we're going to try to use Spirent if there's more worry involved and there's more rumination.

But if somebody's having a panic attacks or an anxiety and having a fast heartbeat and they're feeling like they're going to die because of a panic attack, we will often try to go a little bit different direction for them.

We might use Xanax initially but eventually we want to transition them over to the medications that are primarily increasing serotonin.

I mentioned Lexapro before being helpful for some people but not everybody for depression.

Now that same class that can be helpful for anxiety in some cases.

So we might use Zoloft.

Paxil has been used for years.

We might use the antiepileptic medications.

We're commonly using those for anxiety now such as gabapentin also known as Neurontin.

We're using pregabalin.

Pregabalin is also known as Lyrica.

So those are other options outside the so-called benzodiazepines as a means of relieving anxiety.

Ron, thanks for your call.

Let's go to our next e-mail question.

Our next e-mail question reads Dr. Farber, I keep hearing the phrase burnout in regards to people and their jobs.

What exactly is this and how can it be medically treated?

Burnout is a condition basically where you were overwhelmed with your job duties and you're losing your passion for your job and you get to the point where you become cynical, you become sarcastic on the job and you just don't care so much and it's going to affect your performance and it affects your empathy toward other people and the passion that you might have initially had at one point time for the job.

It's fading away.

You're losing interest.

You don't want to study new technology concerning your work environment.

>> You just don't want to be there anymore.

People get burnt out not uncommonly because they are getting stuck with the current type of job they are experiencing.

I will tell people that when they're getting burnout try to figure out ways outside the box within your capacity to be able to mix it up a little bit on the job and learn new skills and try to get some variety in the job itself.

So the problem with burnout is doing the same thing every day and having the perception that you're not really making a difference with people who are getting burnout.

I try to emphasize to them how they could be making a difference, try to identify ways that they are helping other people beyond how they might realize.

So people who are getting burnout often feel like it doesn't make a difference whether they show up or not and they're doing the same type of things day by day with burnout.

It's also important that you do as much as you can't outside the work environment.

So it's important not to identify yourself as an employee or a worker so to speak, identify yourself as a well-rounded person who might have other interests with your family, with hobbies, with outside activities.

Exercise is extremely important on a day to day basis, especially when someone is getting burnout now burnout does not automatically equal depression if you get to the point where you have burnout and that leads to clinical depression, that's where you're having difficulty with worry and anxiety.

Worry and anxiety typically cascades into insomnia and when you start having difficulty with sleep this front part of the brain here the thinking part of the brain and that doesn't work so well you don't rationalize you don't think through your kind of difficulty so much anymore so you can't rationalize your day to day experiences so well so you can't think what might be the best thing to do and you don't think look at things objectively.

>> So lack of sleep impairs your judgment in your brain and that cascades to depression with depression.

You have trouble with not only feeling sad but you don't enjoy things so much anymore.

You're not as motivated.

You don't want to talk to people.

You start to withdrawal sometimes it'll affect your appetite, worry too much to eat too little.

Sometimes it will affect your energy level and some people will pay when they get really anxious depressed but other people will just kind of crawl up into a hole and they don't move and they become more socially withdrawn.

>> So the cascade that we often see can be start with burnout where you get burnout in your life circumstances or your job and you think why am I doing this?

We often talk about that as being a mid-life crisis not uncommonly people get burnout and they perceive I just need to quit my job and their perception is they just need to quit their job.

Then they have another chapter of their life they have to consider and when they go to the next chapter of their life upon retirement they have to figure out what to do then and sometimes that will lead to some anxiety, some difficulty with sleep and then trouble thereafter with depression.

>> So changing your life circumstances can be helpful but be aware that if you change your life circumstances keep things keep things of varied so that you're doing little this little that and you're keeping things interesting and a lot of different ways.

>> Thanks for your question.

>> Let's go to our next caller.

Hello Rick.

Welcome to Matters of Mind Rick.

>> You want to know about testosterone levels?

Do they affect your mental health like anxiety and depression?

They can, Rick.

It's been debatable whether it's worthwhile for men to have testosterone supplementation one way or another as you likely are aware, once you have testosterone supplementation you might need to have it ongoing testosterone does affect norepinephrine and to some degree dopamine which can be energizing, motivating and can give you a sense of well-being and as long as you keep the levels within the normal range they can sometimes be safely used.

But we always have to be aware of any detrimental effects with testosterone and weigh the pros and cons with your urologist, with your primary care clinician to sort that out.

But sometimes we will find testosterone could be helpful as a psychiatrist I often hear the other extreme where you'll have a man who is using testosterone supplementation but it's kind of the high level so men can as you can imagine, get more irritable, angry and more moody with excessively high testosterone levels.

I hear about that oh sometimes with bodybuilders using anabolic steroids where they get irritable, moody, sometimes even violent.

So you want to make sure not to go to that extreme but testosterone supplementation needs to be talked over with your urologist or primary care clinician to see what might be the best route for you to go there.

>> Rick, thanks for your call.

Let's go to our next e-mail.

Our next e-mail reads Dear Dr. Farber, do psychiatrists still ask people why they hate their mothers?

And we're coming up on Thanksgiving.

>> It the whole concept of hating the mother goes back to one hundred years ago.

Fifty years ago when psychiatrist recognized that childhood traumas as I mentioned before can impact a person's mental health .

Now who's the primary care caregiver of a child?

It's usually the mother you might say, well, gee, I know some fathers who are caregivers and some very good caregivers.

>> That's sometimes can be the case but usually historically it's been a mother who is the primary caregiver giver.

So as you're growing up at your mother upon who you might rely and if you have adverse childhood experiences your mother somehow might be involved.

So years ago psychodynamic psychiatrist psychoanalyst might talk extensively about your relationship usually with both parents but it would often come back to the mother.

Mothers typically will bond with their babies more more intensely than the fathers and I say that from a neurochemical standpoint because when mothers give birth to a baby this little hormone called oxytocin which comes from the pituitary gland goes sky high.

It's like 80 times higher after a mother delivers baby.

Oxytocin interestingly enough, does not go up for a father but it goes up for four mothers when they have a baby the father of the baby will not have an elevated oxytocin level .

Oxytocin is the bonding hormone.

It's the loving hormone.

So from a neurobiological standpoint the mother bear concept where the mother becomes very protective of the baby.

Yeah, that's a real phenomenon and all of that can be from oxytocin now elevated oxytocin in combination with sometimes what happens is thyroid thyroiditis where the thyroid gland which is in the throat, the thyroid gland gets inflamed and there's an auto immune response.

It's similar to Hashimoto's thyroiditis where you have high antibodies and you can have low thyroid that can occur.

So when you have the combination of high oxytocin and the hypothyroidism that can give you mental health issues not only like anxiety but also obsessive compulsive disorder not uncommon for a lot of women who give birth to babies depression postpartum depression is not uncommon as well.

>> So we don't measure oxytocin level oxytocin is a brain protein that we don't and we really can't get ready access to.

But we can measure thyroid levels.

We can measure thyroid antibodies and determine if there's any thyroid disturbances.

They're following a mothers giving birth.

Now obviously I'm evading your question about our talking about hating the mothers in psychoanalytic sessions but the whole idea there is when when a psychiatrist asks you did you hate your mother, it comes down.

We don't ask that by the way anymore.

That was asked twenty , thirty years ago.

But when a psychiatrist did ask that the reason for that questioning was to determine what kind of childhood trauma you might have had and the mothers always got blamed and it was inadvertent but the mothers always got blamed for a lot of childhood traumas.

Childhood traumas can come in many shapes and sizes if you look up the adverse childhood experiences scale it's online, it's Internets on the Internet it's not copyright protected the ACE questionnaire is something that many psychiatrists myself included will give to patients on their very first appointment.

>> It has to do with childhood adverse experiences and it's the ones that are most connected with physical problems later on like diabetes, cancer, heart disease, lung disease and also more connected with mental health problems.

If you score four out of the ten or more it's highly addictive.

You're going to have a lot of physical problems and if you score even a one, two or three it can be a factor with mental health problems but that higher the score the more likely you're going to have a mental health problems.

People in my practice when I see the first time it's not uncommon they'll score of four or even a six or eight or an eight out of ten when you look at those specific traumas that are on that adverse childhood experiences scale now why is that important?

Well, when you see a high score on the adverse childhood experience scale it's predictive that person might have some trouble with trust, intimacy.

Think about it if you've been traumatized as a child it actually affects physically your brain development and with your brain development being altered and in such a way you might have more trouble with feeling jumpy more you might be more anxious, more irritable.

So there's some neurochemical things going on there that well as an adult they were actually they actually had their origin in your childhood.

So yeah, on one hand you want to try to work through some of those issues perhaps in psychotherapy but we're going to choose our medications accordingly based on how your brain got evolved, how your brain grew as it did did childhood experiences affected did a head injury affect your brain growth?

>> Did the use of marijuana which suppresses the brain growth, was that a factor as you were growing up so all these different issues might come about.

But as I mentioned before, if you've had a lot of adverse childhood experiences that are showing up on that ACE questionnaire, it's a pretty good predictor that you're not going to do so well with a serotonin medications that are often used first line such as Lexapro, Zoloft, Celexa, Paxil, Prozac these are medications that typically don't work for people who have had a lot of adverse childhood experiences and it's thought that with adverse childhood experiences it alters the way your brain is able to to transmit serotonin and the serotonin doesn't transmit and doesn't interact with the receptors as it should.

So in those cases we have to go to other medications that have different mechanisms of action than just affecting the serotonin transporters like something like Lexapro, Zoloft, Paxil, Celexa or those medications in that class might do a very good question.

Thanks for thanks for your question.

Unfortunately I'm out of time for this evening if you have any questions that I can answer on the air about mental health difficulties, you're welcome to contact me at Matters of the Mind.

That's all.

One word at WFB EDG I'm psychiatrist Jay Fawver and you've been watching Matters the Mind on PBS wane God willing and PBS willing.

I'll be back again next week.

Thanks for watching and have a good night